President's Message

March 2025

Dear MDACC Chapter Members:

The work of the MDACC is continual! Two important things to note this month in the advocacy arena are below.

Sammy Zakaria, MD, FACC

President, Maryland Chapter ACC

REGULATORY

Your Maryland Chapter ACC is actively involved at a national level engaging with stakeholders about policies related to Medicare reimbursement on behalf of the cardiology community. This month our carrier advocatory committee representative Darpan Bansal, MD, FACC, dedicated his time to attending the Novitas/First Coast CAC meeting on Non-invasive US-Extracranial and Upper and Lower Extremities. A summary of the meeting is below about this specific issue and the chapter will be monitoring the issue with help from Heart House staff. If the LCD comes up for this issue or others, we will be sure to comment and let all chapter members know if comments are needed.

LEGISLATIVE

MDACC’s Advocacy Committee, chaired by Stan Liu, MD, FACC, was in Annapolis hosting the Senate Finance and House Ways and Means Committee members. MDACC members got to interact with these lawmakers and talk about cardiology and other preventative steps that could increase heart health for all citizens. Interactions such as these give our elected officials additional knowledge about the realities of patient care and also provide a recourse for future questions.

Summary

The February 18, 2025 CAC meeting addressed a series of questions from the MACs regarding the use of arterial vascular ultrasound (US) and noninvasive physiologic testing in various patient populations, particularly those with varying stages of peripheral artery disease (PAD) or related conditions. The importance of having qualified vascular technologists perform arterial ultrasounds in accredited laboratories due to the technician-dependent nature of the procedure was discussed. Podiatry recommended to CMS that credentials to perform vascular US should not be the same as credentials to do ABIs and PVRs and should be separated with podiatry well able to perform and interpret ABI/ PVR. Medicare has faced challenges in implementing these US requirements due to pushback around the use of portable US machines.

For specific patient populations, such as diabetics and those suspected of arterial insufficiency, initial testing should include Ankle-Brachial Index (ABI) and pulse volume recording before considering ultrasound was the consensus of the four panel providers. Chronic edema alone is not an indication for arterial duplex ultrasound unless accompanied by other symptoms like leg pain.

Is Noninvasive physiologic testing crucial for asymptomatic patients at risk for cardiovascular disease (CVD) and those with typical risk factors for atherosclerosis? This was a question with early negative discussion (testing asymptomatic without exam evidence) but was followed later with more positive discussion.

Regular surveillance with arterial duplex ultrasound is recommended for patients who have undergone endovascular or open revascularization to monitor for complications. However, routine annual imaging is not advised unless specific indications are present. The panel recommended ABI as the first line of testing after physical examination, with arterial duplex ultrasound limited and reserved for cases where intervention is being considered. Concomitant arterial duplex ultrasound and noninvasive physiologic testing should not be performed on the same date for the same diagnosis unless there are signs and symptoms of disease needing revascularization intervention by discussion. Additionally, arterial duplex ultrasound is not recommended for patients with isolated lymphedema or stable intermittent claudication unless there is a plan to intervene by panel discussion.

Noninvasive physiologic studies are useful for predicting ischemic events and assessing the likelihood of wound healing, while Intima-Media Thickness (IMT) measurement is primarily used for research purposes and not commonly in clinical practice for assessing carotid artery disease in Medicare patients with TIA symptoms. The panel felt that peripheral CT angiography was rarely necessary ("unless you own the CT scanner") and that vascular arterial US was the necessary component for intervention data. Moreover, the panel affirmed that vascular arterial US was best performed by an interventionalist for data needed for revascularization and probably should not be performed by a diagnostic only physician unless the interventionalist was allowed to repeat and bill for the repeat study.

CAC panelists and members will receive a set of polling questions to complete documenting takeaways from the evidentiary meeting. Using the information gathered, Novitas/First Coast will determine if an LCD (revision) development is warranted. If one is proposed, it will be posted for public comment.